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This page serves as a central resource to find key information on important topics such as infection prevention, implant related complications, perioperative planning, and medical management. The content is split into pediatric and adult teams, and includes such tools as checklists, guidelines, key publications, videos, and webinars.

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The Burden of Muscleskeletal Disease

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Pediatric

PREOPERATIVE

Indications and Classification

  • Adams AJ, Refakis CA, Flynn JM, Pahys JM, Betz RR, Bastrom TP, Samdani AF, Brusalis CM, Sponseller PD, Cahill PJ. Surgeon and Caregiver Agreement on the Goals and Indications for Scoliosis Surgery in Children With Cerebral Palsy.  Spine Deform. 2019 Mar;7(2):304-311. doi: 10.1016/j.jspd.2018.07.004.
    • 126 surgeon/caregiver pairs were surveyed to rank surgical indications in neuromuscular scoliosis. The greatest area of agreement was in improving sitting balance(69%) followed by to prevent pulmonary compromise and pain improvement.
       
  • Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am. 2001 Aug;83(8):1169-81.
    • The lack of a reliable, universally acceptable system for classification of adolescent idiopathic scoliosis made comparisons between various types of operative treatment an impossible task.  This new two-dimensional classification of adolescent idiopathic scoliosis, as tested by two groups of surgeons, was shown to be much more reliable than the King system
       
  • Watanabe K, Lenke LG, Matsumoto M, Harimaya K, Kim YJ, Hensley M, Stobbs G, Toyama Y, Chiba K. A novel pedicle channel classification describing osseous anatomy: how many thoracic scoliotic pedicles have cancellous channels?  Spine (Phila Pa 1976). 2010 Sep 15;35(20):1836-42. doi: 10.1097/BRS.0b013e3181d3cfde.PMID: 20802397
    • This study aimed to quantify pedicles in 53 consecutive scoliosis patients according to the pedicle morphology.  Pedicles that had a large cancellous channel were labelled as Type A, those with small cancellous channels were Type B, the all “cortical channel” was labelled a Type C, and a Type D pedicle was when the pedicle probe could not locate a channel and hence this was described as a “slit/absent channel”.
       
  • Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. JAMA. 2003 Feb 5;289(5):559-67. doi: 10.1001/jama.289.5.559.PMID: 12578488
    • Prospective natural history study of 117 untreated patient at 50-year follow-up, Cwith 62 age- and sex-matched volunteers. An increased risk of shortness of breath was also associated with the combination of a Cobb angle greater than 80 degrees and a thoracic ape. S-six (61%) of 109 patients reported chronic back pain compared with 22 (35%) of 62 controls
       
  • Williams BA, Matsumoto H, McCalla DJ, Akbarnia BA, Blakemore LC, Betz RR, Flynn JM, Johnston CE, McCarthy RE, Roye DP Jr, Skaggs DL, Smith JT, Snyder BD, Sponseller PD, Sturm PF, Thompson GH, Yazici M, Vitale MG. Development and initial validation of the Classification of Early-Onset Scoliosis (C-EOS). J Bone Joint Surg Am. 2014 Aug 20;96(16):1359-67. doi: 10.2106/JBJS.M.00253.
     

Preoperative Optimization and Risk Assessment

  • Boachie-Adjei O, Yagi M, Sacramento-Dominguez C, Akoto H, Cunningham ME, Gupta M, Hess WF, Lonner BS, Ayamga J, Papadopoulos EC, Sanchez-Perez-Grueso F, Pelise F, Paonessa KJ, Kim HJ; FOCOS Spine Research Group. Surgical Risk Stratification Based on Preoperative Risk Factors in Severe Pediatric Spinal Deformity Surgery.  Spine Deform. 2014 Sep;2(5):340-349. doi: 10.1016/j.jspd.2014.05.004. Epub 2014 Aug 27.PMID: 27927331
    • Retrospective review of consecutive pediatric spine deformity surgeries (n=145) to create a surgical risk classification.  Five levels of risk stratification were established based on curve magnitude, etiology, ASA grade, number of fusion levels, preoperative neurologic status, BMI, and type of osteotomies.  No single parameters predicted postoperative complications. However, a higher-level score in the classification trended toward increased intraoperative neuromonitoring change and postoperative neurologic risk.
       
  • Luhmann SJ, Smith JC. Preoperative MRSA Screening in Pediatric Spine Surgery: A Helpful Tool or a Waste of Time and Money?  Spine Deform. 2016 Jul;4(4):272-276. doi: 10.1016/j.jspd.2015.12.006. Epub 2016 Jun 16.
    • Retrospective review from single surgeon spine database (n=339) to assess usefulness of preoperative nasal swab screening for Staphylococcus aureus in pediatric spine surgery patients.  MRSA was positive in 6% of patients and MSSA was positive in 16% of patients.  In 6.5% of patients, antibiotic resistance to cefazolin or clindamycin was identified.  Authors concluded that S. aureus preoperative nasal swab permitted adjustment of perioperative antibiotics in up to 6.5% of patients.
       
  • Luhmann SJ, Furdock R. Preoperative Variables Associated With Respiratory Complications After Pediatric Neuromuscular Spine Deformity Surgery. Spine Deform. 2019 Jan;7(1):107-111. doi: 10.1016/j.jspd.2018.05.005.
    • Retrospective review from a single surgeon database (n=111) to correlate preoperative variables with the risk of respiratory complications in neuromuscular spine deformity.  It showed that any history of pneumonia and presence of a gastrotomy tube correlated with an increased risk of postoperative respiratory complications with both univariate and multivariate analyses.  Univariate analysis of low serum transferrin and presence of a tracheostomy were suggestive of increased postoperative respiratory complications.
       
  • Matsumoto H, Campbell M, Minkara A, Roye DP, Garg S, Johnston C, Samdani A, Smith J, Sponseller P, Sturm PF, Vitale M; Children’s Spine Study Group; Growing Spine Study Group.
    Paper #45: Development of a Risk Severity Score (RSS) Predicting Surgical Site Infection in Early Onset Scoliosis: Identifying High-Risk Patients. Spine Deform. 2017 Nov;5(6):464-465. doi: 10.1016/j.jspd.2017.09.048.PMID: 31997165
    • Multicenter retrospective cohort study of early onset scoliosis patients (n=1,168) undergoing spine deformity surgery.  A Risk Severity Score was developed to quantify the risk for surgical site infection.  The model predicted 3.3% probability of SSI in patients with no risk factors and 68.4% probably in patients with myelomeningocele, GI, endocrine, and pulmonary comorbidities, developmental delay, urinary incontinence, and VP shunt. 
       
  • Mistovich RJ, Jacobs LJ, Campbell RM, Spiegel DA, Flynn JM, Baldwin KD. Infection Control in Pediatric Spinal Deformity Surgery: A Systematic and Critical Analysis Review. JBJS Rev. 2017 May;5(5):e3. doi: 10.2106/JBJS.RVW.16.00071.
    • Review article.  The authors reviewed 167 studies related to risk factors and interventions for reducing surgical site infections in pediatric spine deformity surgery.  Articles were stratified by diagnosis type (AIS, EOS, neuromuscular) and level of evidence.  Preventative strategy topics included use of intrawound antibiotics, preparation and irrigation, dressings, intravenous antibiotics, wound closure, implants, drains, bone graft, dual attending surgery, and pelvic fixation.  Modifiable risk factors reviewed consisted of obesity, hypothermia, duration of surgery, incontinence, and malnutrition.
       
  • Miyanji F, Slobogean GP, Samdani AF, Betz RR, Reilly CW, Slobogean BL, Newton PO. Is larger scoliosis curve magnitude associated with increased perioperative health-care resource utilization?: a multicenter analysis of 325 adolescent idiopathic scoliosis curves. J Bone Joint Surg Am. 2012 May 2;94(9):809-13. doi:10.2106/JBJS.J.01682.PMID: 22552670
    • 325 patients from a multicentre, surgical AIS database were analyzed and the authors found that larger curves were associated with increased utilization of perioperative health-care resources, namely OR time (significant increase), greater number of levels fused, and for every 10 degree increase in curve size, there was a 1.5 times higher odds of receiving a blood transfusion.
       
  • O'Brien MF, Lenke LG, Bridwell KH, Blanke K, Baldus C.  Preoperative spinal canal investigation in adolescent idiopathic scoliosis curves > or = 70 degrees.  Spine (Phila Pa 1976) 1994 Jul 15;19(14):1606-10.  doi: 10.1097/00007632-199407001-00009.
    • Prospective study of AIS patients (n=33) with curve > 70 degrees to assess for presence of spinal cord anomalies.  CT scan (n=3) or MRI (n=30) showed no neurologic abnormalities in any patients, and all patients were treated surgically without any neurologic sequelae.  Authors concluded preoperative investigation of the neural axis is not mandatory for large, typical AIS curves.
       
  • Sedra F, Shafafy R, Sadek AR, Aftab S, Montgomery A, Nadarajah R. Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach.  Global Spine J. 2021 Mar;11(2):240-248. doi: 10.1177/2192568220901692. Epub 2020 Feb 13.
    • Review article.  Describes a multidisciplinary approach to optimize patients with neuromuscular disease undergoing scoliosis surgery as it relates to pulmonary, gastrointestinal, nutritional, cardiac, genitourinary, and wound complications, blood loss during surgery, and neurologic injury. 
       
  • White KK, Bompadre V, Krengel WF, Redding GJ; Pediatric Spine Study Group. Low Preoperative Lung Functions in Children With Early Onset Scoliosis Predict Postoperative Length of Stay.  J Pediatr Orthop. 2021 Apr 1;41(4):e316-e320
    • Prospective data collection from a multicenter registry.  Evaluated preoperative lung function studies in Children with EOS (n=525) to correlate with length of hospital stay following growth friendly or definitive spine fusion surgeries.  Only preoperative FVC < 50% predicted was associated with increased risk of postoperative length of stay > 7 days.
       

Pre-operative Planning and Level Selection

  • Baghdadi S, Cahill P, Anari J, Flynn JM, Upasani V, Bachmann K, Jain A, Baldwin K; Harms Study Group. Evidence Behind Upper Instrumented Vertebra Selection in Adolescent Idiopathic Scoliosis: A Systematic and Critical Analysis Review. JBJS Rev. 2021 Sep 9;9(9). doi: 10.2106/JBJS.RVW.20.00255.
    • The authors conducted a systematic review to appraise various recommendations with regards to Upper Instrumented Vertebra (UIV) selection in Adolescent Idiopathic Scoliosis. Current guidelines for selection of UIV is still mostly inconclusive with mixed/ low-level evidence.
       
  • Beauchamp EC, Lenke LG, Cerpa M, Newton PO, Kelly MP, Blanke KM; Harms Study Group Investigators. Selecting the "Touched Vertebra" as the Lowest Instrumented Vertebra in Patients with Lenke Type-1 and 2 Curves: Radiographic Results After a Minimum 5-Year Follow-up. J Bone Joint Surg Am. 2020 Nov 18;102(22):1966-1973.  doi: 10.2106/JBJS.19.01485.PMID: 32804885
    • The authors reviewed a multicenter database and analyzed the data of 299 Lenke 1 and 2 patients (minimum follow-up of 5 years. The authors recommended fusion to the ‘Touched Vertebra” (TV) for Lenke 1 and 2 curves. Patients with ‘A’ Lumbar Modifier who had fusion cephalad to the TV were at higher risk of Lower Instrumented Vertebra (LIV) translation with risk of poorer long term outcome.
       
  • Chan CM, Swindell HW, Matsumoto H, Park HY, Hyman JE, Vitale MG, Roye DP Jr, Roye BD. Effect of Preoperative Indications Conference on Procedural Planning for Treatment of Scoliosis.  Spine Deform. 2016 Jan;4(1):27-32. doi: 10.1016/j.jspd.2015.05.003. Epub 2015 Dec 23.
    • The authors evaluated the effect of preoperative indications conference on the surgical plan in 107 scoliosis surgeries. Change in surgical plan occurred in 28% of index surgeries and 8% of revision surgeries. Index surgeries for AIS/JIS patients were the most likely to be influenced by preoperative indications conference.
       
  • Marciano G, Ball J, Matsumoto H, Roye B, Lenke L, Newton P, Vitale M; Harms Study Group. Including the stable sagittal vertebra in the fusion for adolescent idiopathic scoliosis reduces the risk of distal junctional kyphosis in Lenke 1-3 B and C curves. Spine Deform. 2021 May;9(3):733-741. doi: 10.1007/s43390-020-00259-2. Epub 2021 Jan 5.
    • In this retrospective multicenter cohort study, the authors reviewed 856 AIS patients, 114 patients of which had discordant Coronal Last Touched Vertebra (c-LTV) and Sagittal Stable Vertebra (SSV). Among the 114 patients, patients with Lenke 1-3 with B/C Lumbar Modifier who were fused short of the SSV were 9 times more likely to develop distal junctional kyphosis.(DJK) However, those who were fused short of the SSV but did not develop DJ had better patient reported outcome measures.
       
  • Medrriman M, Hu C, Noyes K, Sanders J. Selection of the Lowest Level for Fusion in Adolescent Idiopathic Scoliosis-A Systematic Review and Meta-Analysis. Spine Deform. 2015 Mar;3(2):128-135. doi: 10.1016/j.jspd.2014.06.010. Epub 2015 Mar 4.
    • In this systematic review and meta-analysis to analyse the association between the lowest level of fusion to the occurrence of back pain following surgery. 8 retrospective studies were included in the analysis. Although there was a trend towards more back with fusion to L4 or L5 compared to L3 and cephalad, the association was not statistically significant. Therefore, the effect of distal level of fusion on post-oeprative low back pain is still not known.
       
  • Miyanji F, Newton PO, Perry A, Vanvalin S, Pawlek J. Is the lumbar modifier useful in surgical decision making?: defining two distinct Lenke 1A curve patterns. Spine Nov 33(23):2545 – 51,2008.
    • 93 patients with Lenke 1A and 1B curves and 2 year f/u were analyzed. Lenke 1A curves were subdivide into 1A-L and 1A-R depending on the tilt of L4 (1A-L, L4 tilted to left and 1A-R, L4 tilted to right). Those that had L4 tilted to the left (1A-L) behaved like Lenke 1B curves with a similar location of the stable vertebrae and a median LIV of T12.  Lenke 1A-R had more distal stable vertebrae (L3 and L4) with significant more distal median LIV of L2.  The authors propose that the A and B lumbar modifier for Lenke 1 curves does not describe distinct curve types within Lenke 1curve types and propose a subdivision of Lenke 1A curves into 1A-R and 1A-L, depending on the tilt of L4.
       
  • Sardar ZM, Ames RJ, Lenke L. Scheuermann's Kyphosis: Diagnosis, Management, and Selecting Fusion Levels. J Am Acad Orthop Surg. 2019 May 15;27(10):e462-e472. doi: 10.5435/JAAOS-D-17-00748.PMID: 30407981. Review article.
    • In this review article, the diagnosis, management and selection of fusion levels were discussed. Surgical indication included curved that has progressed beyond 70 degrees. There is a trend towards an all posterior approach for surgery. Upper instrumented vertebrae should include at least the upper end vertebrae but a more proximal UIV selection could reduce the risk of proximal junctional kyphosis. The authors recommended inclusion of the sagittal stable vertebrae in the fusion block to reduce the risk of distal junctional kyphosis.
       
  • Shao X, Sui W, Deng Y, Yang J, Chen J, Yang J. How to select the lowest instrumented vertebra in Lenke 5/6 adolescent idiopathic scoliosis patients with derotation technique. Eur Spine J. 2022 Apr;31(4):996-1005. doi: 10.1007/s00586-021-07040-7. Epub 2021 Nov 6.
    • The authors reported the outcome of 53 Lenke 5/6 patients in this retrospective study. The criteria for LIV selection were most cephalad vertebra touched by CSVL, Vertebra with grade 2 or less rotation, and vertebra with lowest instrumented vertebra disc angle that can be reversed on lateral bending. Utilising this selection criteria, at minimum 2 years follow up the incidence of adding on phenomenon and coronal decompensation was 3.8% respectively.
       
  • Toll BJ, Gandhi SV, Amanullah A, Samdani AF, Janjua MB, Kong Q, Pahys JM, Hwang SW. Risk Factors for Proximal Junctional Kyphosis Following Surgical Deformity Correction in Pediatric Neuromuscular Scoliosis.  Spine (Phila Pa 1976). 2021 Feb 1;46(3):169-174. doi: 10.1097/BRS.0000000000003755.
    • In this single center retrospective study, 60 pediatric neuromusuclar scoliosis patients were included in the analysis. The incidence of Proximal Junctional Kyphosis (PJK) was 27% and Proximal Junctional Failure (PJF) was 7%. Risk factors for PJK included pre-operative halo-gravity traction, greater C2 sagittal translation, loss of primary curve correction and smaller pre-operative proximal kyphosis.
       
  • Yang J, Andras LM, Broom AM, Gonsalves NR, Barrett KK, Georgiadis AG, Flynn JM, Tolo VT, Skaggs DL. Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis. Spine Deform. 2018 Jan;6(1):38-42. doi: 10.1016/j.jspd.2017.06.007.
    • The authors conducted a retrospective review of data obtained from two centers to analyze the importance of the Sagittal Stable Vertebra(SSV) in prevention of distal junctional  (DJK) in Adolescent Idiopathic Scoliosis (AIS) patients who underwent selective thoracic fusion (STF). Among the 113 patients, the rate of DJK was 17% (LIV cephalad to SSV) vs. 0% (LIV at SSV or distal to it). Selection of LIV at or distal to SSV would minimise risk of DJK.
       

Teams

  • Berry JG, Glaspy T, Eagan B, Singer S, Glader L, Emara N, Cox J, Glotzbecker M, Crofton C, Ward E, Leahy I, Salem J, Troy M, O'Neill M, Johnson C, Ferrari L. Pediatric complex care and surgery comanagement: Preparation for spinal fusion. J Child Health Care. 2020 Sep;24(3):402-410. doi: 10.1177/1367493519864741. Epub 2019 Jul 30.
    • Study looking at the impact of preoperative comanagement with complex care pediatricians (CCP) on patients with neuromuscular scoliosis undergoing spinal fusion.  The study found that those children who had involvement of the CCP team had fewer last minute coordination activities for surgical clearance, and fewer had last minute changes to preoperative plans.  Study was done at a large tertiary referral children’s hospital.
       
  • Flynn JM, Striano BM, Muhly WT, Kraus B, Sankar WN, Mehta V, Blum M, DeZayas B, Feldman J, Keren R.  A Dedicated Pediatric Spine Deformity Team Significantly Reduces Surgical Time and Cost. J Bone Joint Surg Am. 2018 Sep 19;100(18):1574-1580. doi: 10.2106/JBJS.17.01584.PMID: 3023462.
    • Retrospective analysis comparing dedicated OR teams made up a small group of anesthesiologists, CRNA’s, OR nurses and technicians (Dedicated Team) with PSF without dedicated teams in a large hospital setting.  Cases were categorized as I (<12 levels fused, no osteotomies, and a BMI < 25 kg/m2, or II (>= 12 levels fused and or >= 1 osteotomy and/or a BMI >= 25 kg/m2 .  Standardized protocols were developed and implemented.  Neuromuscular and more complex cases were excluded from analysis.  There was almost a 1-2 hour improvement in OR time, and a cost savings in cases where dedicated teams were used.
       
  • Miyanji F, Greer B, Desai S, Choi J, Mok J, Nitikman M, Morrison A.  Improving quality and safety in paediatric spinal surgery: the team approach. Bone Joint J. 2018 Apr 1;100-B(4):493-498. doi: 10.1302/0301-620X.100B4.BJJ-2017-1202.R1.
    • A retrospective consecutive case control study of spine surgeries lasting > 120 minutes of one surgeon before and after the implementation of a paediatric spinal surgical team (PSST) made up of a homogenous group of OR nurses, anesthitists, and IONM technician.  There were significant improvements in operating room time, length of stay, blood loss, and allogenic blood transfusion in the group with a PSST.   Complications were also higher in the pre PSST group compared to those patients with the PSST. There was a 2.4 times increased risk of surgical site infection in the pre PSST group. Of note surgeon experience (which was greater in the PSST group) may have had a confounding effect on the results.

INTRA-OPERATIVE

Neurologic Injury Prevention

Perioperative Blood Management

Infection Prevention

  • Michael G Vitale, Matthew D Riedel, Michael P Glotzbecker, Hiroko Matsumoto, David P Roye, Behrooz A Akbarnia, Richard C E Anderson, Douglas L Brockmeyer, John B Emans, Mark Erickson, John M Flynn, Lawrence G Lenke, Stephen J Lewis, Scott J Luhmann, Lisa M McLeod, Peter O Newton, Ann-Christine Nyquist, B Stephens Richards 3rd, Suken A Shah, David L Skaggs, John T Smith, Paul D Sponseller, Daniel J Sucato, Reinhard D Zeller, Lisa Saiman. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013 Jul-Aug;33(5):471-8. doi: 10.1097/BPO.0b013e3182840de2.
    • A 14-statement consensus reached through a Delphi method regarding best practices for prevention of SSI in high-risk pediatric patients. It addresses pre-op, intraop and post-operative practices.
       
  • Michael P Glotzbecker, Tricia A St Hilaire, Jeff B Pawelek, George H Thompson, Michael G Vitale, Children’s Spine Study Group; Growing Spine Study Group. Best Practice Guidelines for Surgical Site Infection Prevention With Surgical Treatment of Early Onset Scoliosis. J Pediatr Orthop. 2019 Sep;39(8):e602-e607. doi: 10.1097/BPO.0000000000001079.
    • A 22-statement consensus reached through a Delphi method regarding best practices for prevention of SSI in EOS. It addresses pre-op, intraop and post-operative practices.
       
  • Matsumoto H, Campbell M, Minkara A, Roye DP, Garg S, Johnston C, Samdani A, Smith J, Sponseller P, Sturm PF, Vitale M; Children’s Spine Study Group; Growing Spine Study Group. Paper #45: Development of a Risk Severity Score (RSS) Predicting Surgical Site Infection in Early Onset Scoliosis: Identifying High-Risk Patients. Spine Deform. 2017 Nov;5(6):464-465. Spine Deform. 2017 Nov;5(6):464-465. doi: 10.1016/j.jspd.2017.09.048.PMID: 31997165
    • Retrospective study assessing Risk Severity score that allows to predict SSI risk in patients with EOS. The presence of myelomeningocele, GI, endocrine, and pulmonary comorbidities, developmental delay, urinary incontinence, and ventriculoperitoneal shunt increase the risk of infection to 68.4% while the absence of these comorbidities lowers the risk to 3.3%.
       
  • Luhmann SJ, Smith JC. Preoperative MRSA Screening in Pediatric Spine Surgery: A Helpful Tool or a Waste of Time and Money? Spine Deform. 2016 Jul;4(4):272-276. doi: 10.1016/j.jspd.2015.12.006. Epub 2016 Jun 16.
    • In 6.5% of the cases, the use of nasal swab as a method for screening the presence of MRSA changed the preoperative antibyotic regime due to the presnece of resistance (4.7% MRSA and 1.8% MSSA).
       
  • Mistovich RJ, Jacobs LJ, Campbell RM, Spiegel DA, Flynn JM, Baldwin KD. Infection Control in Pediatric Spinal Deformity Surgery: A Systematic and Critical Analysis Review. KD. JBJS Rev. 2017 May;5(5):e3. doi: 10.2106/JBJS.RVW.16.00071.
    • Systematic review on the risk of SSI in pediatric population: There is insufficient evidence to recommend either topical gentamycin or vancomycin, the use of irrigation (and other surgical preparation solutions), a specific type of dressing (including incisional vacuum and the participation of two attendings. There is grade B recommendation for any type of closure methods, in favor of titanium (instead of stainless steel), against the use of drains, the increased risk with the use of pelvic fixation (no difference with S2A1 screws), intraop hypothermia does not increase the risk of SSI and that length of surgery doesn’t impact SSI rates. There is grade C recommendation in favor of the use of iv atb, mixed evidence regarding allografts, mixed reviews regarding obesity, incontinence and malnutrition as modifiable factors.
       

Navigation and Enabling Technology

POSTOPERATIVE

Optimizing Length of Stay in Adolescent Idiopathic Scoliosis Surgery

  • Fletcher ND, Glotzbecker MP, Marks M, Newton PO,Harms Study Group. Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.  Spine (Phila Pa 1976). 2017 May 1;42(9): E547-E554. doi: 10.1097/BRS.0000000000001865.PMID: 28441684 
    • An expert panel of 26 pediatric spine surgeons opined upon a detailed literature review and consensus was sought using the Delphi process. Consensus (agreement > 80%) was reached to support 19 best practice guideline (BPG) measures for postoperative care supporting non-ICU admission, perioperative pain control (supporting PCA pump, gabapentin, antispasmodics and ketorolac use; limiting epidural, early transition to oral narcotics), dietary management (supporting early clear liquids, chewing gum, bowel regimen and antiemetics), physical therapy (sitting, standing and twice daily PT POD#1), limiting postoperative radiographs, and indications for discharge (pain tolerated with oral analgesic, tolerating regular diet, bowel movement unnecessary, meeting PT goals).
       
  • Fletcher ND, Murphy JS, Austin TM, Bruce RW Jr, Harris H, Bush P, Yu A, Kusumoto H, Schmitz ML, Devito DP, Fabregas JA, Miyanji F. Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis.  Spine Deform. 2021 Jul; 9(4): 1013-1019. doi: 10.1007/s43390-020-00282-3. Epub 2021 Jan 18.PMID: 33460022
    • A prospective dual-center study of patients treated using an ERAS pathway (203 patients) or a traditional discharge (TD) pathway (73 patients) was performed with focus on pain at discharge, quality of life at one month, and return to school/work. LOS was 55% less in the ERAS group (4.8 days TD vs. 2.2 days ERAS, p < 0.001). Regression analysis showed no difference in Visual Analog Score (VAS) score at discharge or quality of recovery using the QOR9 instrument between groups at follow up. There was no difference in return to school and parents' return to work between the groups.
       
  • Muhly WT, Sankar WN, Ryan K, Norton A, Maxwell LG, DiMaggio T, Farrell S, Hughes R, Gornitzky A, Keren R, McCloskey JJ, Flynn JM. Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis. Pediatrics. 2016 Apr; 137(4): e20151568. doi: 10.1542/peds.2015-1568. Epub 2016 Mar 23. PMID: 27009035
    • A quality improvement initiative was undertaken to assess a standardized rapid recovery pathway (RRP). Functional recovery was assessed using LOS and average daily pain scores. Process measures were medication adherence and order set utilization, balancing measure was 30-day readmission rate. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. Gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of the RRP.
       
  • Yang J, Skaggs DL, Chan P, Villamor GA, Choi PD, Tolo VT, Kissinger C, Lehman A, Andras LM. High Satisfaction in Adolescent Idiopathic Scoliosis Patients on Enhanced Discharge Pathway. J Pediatr Orthop. 2020 Mar;40(3): E166-170. doi: 10.1097/BPO.0000000000001436.PMID: 31403990
    • 46 prospectively enrolled patients were evaluated with a survey at their first postoperative clinic visit for satisfaction with an enhanced discharge pathway for PSF and whether they felt that their length of stay was appropriate. 80% of patients felt that they were discharged at an appropriate time (mean, 3.2 d) and had a trend toward shorter stays, whereas 20% felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction.
       

Optimizing Length of Stay in Neuromuscular Scoliosis Surgery

  • Bellaire L., Bruce Jr R., Ward L., Bowman C., Fletcher N. Use of an Accelerated Discharge Pathway in Patients With Severe Cerebral Palsy Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis. Spine Deform. 2019 Sep; 7(5): 804-811. doi: 10.1016/j.jspd.2019.02.002. PMID: 31495482 
    • 74 patients with GMFCS class 4/5 CP undergoing PSF were reviewed. Thirty consecutive patients were cared for using a traditional discharge (TD) pathway, and 44 patients were subsequently treated using an accelerated discharge (AD) pathway. LOS was 19% shorter in patients managed with the AD pathway (AD 4.0 days vs. TD 4.9 days). There was no difference between groups with respect to age at surgery, GMFCS class, preoperative curve magnitude, pelvic obliquity, kyphosis, postoperative curve correction, fusion to the pelvis, or length of fusion between groups. LOS remained significantly shorter in the AD group by 0.9 days when controlling for EBL and length of surgery. There was no significant difference in wound complications, return to the operating room, or medical readmissions between groups.
       
  • Fletcher ND, Bellaire LL, Dilbone ES, Ward LA, Bruce RW Jr. Variability in length of stay following neuromuscular spinal fusion. Spine Deform. 2020 Aug; 8(4): 725-732. doi: 10.1007/s43390-020-00081-w. Epub 2020 Feb 14.PMID: 32060807
    • 197 patients with NMS underwent PSF at a single hospital by two surgeons with a post-operative care pathway emphasizing early mobilization, rapid transition to enteral feeds, and discharge prior to first bowel movement. Severely involved cerebral palsy (CP) patients (GMFCS 4/5) were more likely to have extended stays than GMFCS 1-3 patients. Radiographic predictors included major coronal Cobb angle and pelvic obliquity. Intraoperative predictors included longer surgical times, greater numbers of levels fused and need for intraoperative or postoperative blood transfusion. The need for ICU admission and development of a pulmonary complication were significantly more likely to extend hospital stay.
       
  • Shaw KA, Heboyan V, Fletcher ND, Murphy JS. Comparative cost-utility analysis of postoperative discharge pathways following posterior spinal fusion for scoliosis in non-ambulatory cerebral palsy patients. Spine Deform. 2021 Nov; 9(6): 1659-1667. doi: 10.1007/s43390-021-00362-y. Epub 2021 May 18.PMID: 34008146
    • An economic decision-analysis model was constructed using a hypothetical 15-year-old male with non-ambulatory CP undergoing PSF. Literature was reviewed to estimate costs, probabilities, and QALYs (age-matched US values, with a CP diagnosis corrective value applied) for identified complication profiles for discharge pathways, and probabilistic sensitivity analysis was performed. Accelerated discharge (AD) pathway resulted in an average cost and effectiveness of $67,069 and 15.4 QALYs compared with $81,312 and 15.4 QALYs for traditional discharge (TD). AD resulted in a 2.1% greater net monetary benefit with a cost-effectiveness ratio of $4361/QALY compared with $5290/QALY in the TD.
       
  • Simpson BE, Kara S, Wilson A, Wolf D, Bailey K, MacBriar J, Mayes T, Russell J, Chundi P, Sturm P. Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis. Hosp Pediatr. 2022 Feb 17: e2021006196. doi: 10.1542/hpeds.2021-006196. Online ahead of print.PMID: 35174385
    • Quality improvement methodology was used to implement a standardized clinical care pathway for NMS patients during their primary spinal surgery. The outcome measure was LOS, and the process measure was percentage compliance with the pathway. Mean LOS decreased from 8.0 to 5.3 days; a statistically significant change based on statistical process control chart rules. Percentage compliance with the NMS pathway improved during the testing and sustain phases, compared with the pretesting phase. LOS variability decreased from pretesting to the combined testing and sustain phases.
       

Narcotic/pain management

Neuromuscular ERAS

  • Tøndevold N, Bari TJ, Andersen TB, Gehrchen M. The Collateral Effect of Enhanced Recovery After Surgery Protocols on Spine Patients With Neuromuscular Scoliosis. J Pediatr Orthop. 2023; 43(6): e476-e480.  
    • This study assessed the indirect impact of implementing ERAS protocols designed for adolescent idiopathic scoliosis (AIS) patients on those with neuromuscular scoliosis (NMS). While the ERAS protocol was specific to AIS patients, a 41% reduction in length of stay (LOS) was observed in neuromuscular scoliosis patients treated in the same ward, indicating a collateral benefit. The study involved 46 patients, 20 pre-ERAS and 26 post-ERAS, with no significant differences in postoperative care in the intensive care unit or 90 day readmission rates between the groups. The results suggest that the holistic training of caregiving staff can have a positive effect even on complex cases like NMS.
  • Shaw KA, Harris H, Sachwani N, et al. 
    Avoiding PICU Admission Following PSF for Neuromuscular Scoliosis in Non-ambulatory Cerebral Palsy Managed with ERAS Protocol. 
    Spine Deform. 2023; 11: 671–676. 
    • This study aimed to identify predictors of PICU (Pediatric Intensive Care) admission for children with non-ambulatory cerebral palsy (GMFCS 4/5) undergoing posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS) within the context of an ERAS protocol. The authors retrospectively reviewed 103 patients managed at two institutions. They found that 38.8% of patients required PICU admission, with pre-existing feeding tubes and surgery lasting more than 5 hours being independent predictors of PICU admission. The study concluded that the majority of these patients could be successfully managed on the hospital floor, highlighting the potential for cost reduction and improved recovery outcomes with ERAS implementation.
  • Fletcher ND, Bellaire LL, Dilbone ES, Ward LA, Bruce RW Jr. 
    Variability in Length of Stay Following Neuromuscular Spinal Fusion. 
    Spine Deform. 2020 Aug; 8(4): 725-732.
    • This study evaluated 197 patients with neuromuscular scoliosis who underwent posterior spinal fusion (PSF) with a focus on factors influencing extended LOS. Early mobilization and rapid transition to enteral feeding were emphasized in the care pathway. Key predictors of prolonged hospitalization included severe cerebral palsy (GMFCS 4/5), major coronal Cobb angles, pelvic obliquity, and the need for postoperative ICU admission or blood transfusion. Radiographic and intraoperative predictors significantly influenced the variability in recovery.
  • Nakamura N, Kawabe Y, Momose T, et al. 
    Adoption of an Enhanced Recovery After Surgery Protocol for Neuromuscular Scoliosis Shortens Length of Hospital Stay. 
    Spine Surg Relat Res. 2024; 8(4): 427-432. 
    • In this retrospective cohort study, 54 pediatric patients with neuromuscular scoliosis (NMS) were compared before and after the implementation of the ERAS protocol. ERAS led to a significant reduction in LOS, from 11.6 to 8.2 days. The study highlights the impact of ERAS in managing intraoperative factors such as blood loss and postoperative care, concluding that ERAS protocols are more influential than intraoperative variables in reducing recovery time. No significant differences were observed in complication rates between the two groups.
  • Simpson BE, Kara S, Wilson A, et al. 
    Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis. 
    Hosp Pediatr. 2022; e2021006196. 
    • This study implemented a standardized postoperative clinical pathway for neuromuscular scoliosis (NMS) patients, aiming to reduce the length of stay (LOS) after surgery. Through quality improvement (QI) methodology, LOS was reduced from 8.0 to 5.3 days. The use of enhanced recovery after surgery (ERAS) protocols, including early mobilization and standardized pain management, was central to this reduction, demonstrating improved adherence to postoperative care protocols and decreased variability in recovery times. 

MAXIMIZING OUTCOMES IN PEDIATRIC SPINE SURGERY

Adding-on Phenomenon in Scoliosis Surgery

Distal Junctional Kyphosis

Proximal Junctional Kyphosis

  • Alzakri A, Vergari C, Van den Abbeele M, Gille O, Skalli W, Obeid I. Global Sagittal Alignment and Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis. Spine Deform. 2019 Mar;7(2):236-244. doi: 10.1016/j.jspd.2018.06.014. PMID: 30660217.
    • Case control study 85 patients.  Evaluation of global sagittal alignment including the cranial center of mass (CCOM) and proximal junctional kyphosis (PJK) in adolescent idiopathic scoliosis (AIS) patients treated with posterior instrumentation.13% incidence of PJK- thought to be a compensatory mechanism, which allows for CCOM-HA( cranial center of mass  ) and, to a lesser extent, OD-HA ( dentiform apophysis of C2)to be invariant.
       
  • Erkilinc M, Baldwin KD, Pasha S, Mistovich RJ. Proximal junctional kyphosis in pediatric spinal deformity surgery: a systematic review and critical analysis. Spine Deform. 2022 Mar;10(2):257-266. doi: 10.1007/s43390-021-00429-w. Epub 2021 Oct 27. PMID: 34704232.
    • 635 papers:
    • There were 4 findings found to contribute to PJK with Grade B evidence in EOS: higher number of distractions, disruption of posterior elements, greater sagittal plane correction.  
    • Five findings with Grade B evidence were found to contribute to PJK in AIS populations: higher pre-operative thoracic kyphosis, higher pre-operative lumbar lordosis, longer fusion constructs, greater sagittal plane correction, and posterior versus anterior fusion constructs.  
       
  • Ferrero E, Bocahut N, Lefevre Y, Roussouly P, Pesenti S, Lakhal W, Odent T, Morin C, Clement JL, Compagnon R, de Gauzy JS, Jouve JL, Mazda K, Abelin-Genevois K, Ilharreborde B; Groupe d’Etude sur la Scoliose (GES). Proximal junctional kyphosis in thoracic adolescent idiopathic scoliosis: risk factors and compensatory mechanisms in a multicenter national cohort. Eur Spine J. 2018 Sep;27(9):2241-2250. doi: 10.1007/s00586-018-5640-y. Epub 2018 Jun 29. PMID: 29959554.
    • Cohort of 365 AIS patients – 2 year f/u: Conclusion PJK is a frequent complication in thoracic AIS, occurring 16%, but remains often asymptomatic (less than 3% of revisions in the entire cohort). An interesting finding is that patients with high pelvic incidence and consequently large LL and TK were more at risk of PJK.
       
  • Lonner BS, Ren Y, Newton PO, Shah SA, Samdani AF, Shufflebarger HL, Asghar J, Sponseller P, Betz RR, Yaszay B. Risk Factors of Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis-The Pelvis and Other Considerations. Spine Deform. 2017 May;5(3):181-188. doi: 10.1016/j.jspd.2016.10.003. PMID: 28449961.
    • Muticenter study, 851 AIS patients:to assess the incidence of PJK. The incidence of PJK in patients after surgery for AIS is 7.05% and varies based on Lenke type. Loss of kyphosis, larger preoperative kyphosis, UIV caudal to the proximal UEV (Lenke 1), UIV at or cephalad to the UEV (Lenke 5), and decreased RCA were the major risk factors for PJK in AIS.
       
  • Zhong J, Cao K, Wang B, Li H, Zhou X, Xu X, Lin N, Liu Q, Lu H. Incidence and Risk Factors for Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis After Correction Surgery: A Meta-Analysis. World Neurosurg. 2019 May; 125: e326-e335. doi: 10.1016/j.wneu.2019.01.072. Epub 2019 Jan 26. PMID: 30690145.
    • Meta- Analysis, 7 studies : The incidence of PJK in patients with AIS was 14%. Proximal implants with screws and instrumentation types with all screws were significantly associated with increased occurrence of PJK. Larger preoperative TK, larger preoperative LL, larger postoperative LL, greater TK change, and greater LL change were also identified as risk factors for PJK in AIS after correction surgery.

Vertebral Body Tethering  

  • Alasadi H, Rajjoub R, Alasadi Y, Wilczek A, Lonner BS. Vertebral body tethering for adolescent idiopathic scoliosis: a review. Spine Deform. 2024 May;12(3):561-575. doi: 10.1007/s43390-023-00806-7. Epub 2024 Jan 29. PMID: 38285164.
    • This article provides a review of the literature reporting the radiographic and clinical outcomes as well as complications, and learning curve associated with the use of Vertebral Body Tethering (VBT) in patients with Adolescent Idiopathic Scoliosis (AIS). VBT was considered a success if there was no subsequent need for a fusion and if the cobb angles were less than 30-35 degrees at skeletal maturity. Reported complications included pulmonary complications, tether breakage, and high rates of reoperations. The impact of patient maturity in achieving successful results is also reviewed.
Adult

PREOPERATIVE

Non-Operative versus Operative Treatment

Radiographic Analysis and Classification of Deformity

Team Based Approaches

Value (Econ)

Pre-operative surgical optimization and modifiable risk factors

Screening

  • Buchlak QD, Yanamadala V, Leveque J-C, Sethi R. Complication avoidance with pre-operative screening: insights from the Seattle spine team. Curr Rev Musculoskelet Med. 2016;9(3):316-326. doi:10.1007/s12178-016-9351-x
    • Standardized preoperative evaluation protocols have been shown to significantly reduce the likelihood of a spectrum of negative outcomes associated with complex adult lumbar scoliosis surgery
    • To increase patient safety and reduce complication risk, an entire medical and surgical team should work together to care for adult lumbar scoliosis patients
    • An evidence-based comprehensive systematic preoperative surgical evaluation process is described
       

Nutrition

  • Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):1082-1085. doi:10.1097/01.brs.0000160842.43482.cd
    • No association between nutrition and development of spinal deformity has been demonstrated
       
  • Adogwa O, Martin JR, Huang K, et al. Preoperative serum albumin level as a predictor of postoperative complication after spine fusion. Spine (Phila Pa 1976). 2014;39(18):1513-1519. doi:10.1097/BRS.0000000000000450
    • Preoperative hypoalbuminemia is an independent risk factor for postoperative complications, 30-day mortality, and increased length of hospital stay after spine surgery for degenerative and deformity causes
    • Should be used more frequently as a prognostic tool to detect malnutrition and risk of adverse surgical outcomes
       
  • Stoker GE, Buchowski JM, Bridwell KH, Lenke LG, Riew KD, Zebala LP. Preoperative vitamin D status of adults undergoing surgical spinal fusion. Spine (Phila Pa 1976). 2013;38(6):507-515. doi:10.1097/BRS.0b013e3182739ad1
    • Vitamin D plays a critical role in establishing optimal bone health, which, in turn, is vital to the success of spinal arthrodesis
    • There is a substantially high prevalence of vitamin D abnormality in the overall population.
    • Although advanced age is a well-established risk factor for hypovitaminosis, young adults undergoing fusion should not be overlooked with regard to vitamin D screening; this age bracket is less likely to have been previously supplemented

Diabetes

Obesity

Smoking

High Risk Patients

INTRAOPERATIVE EXECUTION

Intraoperative Checklists

Team based approaches in the operating room

Intraoperative Neuromonitoring

  • Pelosi L, Lamb J, Grevitt M, Mehdian SMH, Webb JK, Blumhardt LD. Combined monitoring of motor and somatosensory evoked potentials in orthopaedic spinal surgery. Clin Neurophysiol. 2002;113(7):1082-1091. doi:10.1016/s1388-2457(02)00027-5
    • Combined SEPs and multi-pulse TES-MEPs is highly recommended because it provides a safe, reliable and sensitive method of monitoring spinal cord function in spine surgery and has been shown to be superior to single modality techniques.
       

Minimally Invasive versus Open Procedures

Pedicle Subtraction Osteotomy (PSO)

Intraoperative Complications

Dural Tears

  • Iyer S, Klineberg EO, Zebala LP, et al. Dural Tears in Adult Deformity Surgery: Incidence, Risk Factors, and Outcomes. Glob spine J. 2018;8(1):25-31. doi:10.1177/2192568217717973
    • Adult spinal deformity surgery has a 3-10% rate of dural tears in with decompressive techniques being the largest risk factor.
    • Patients who suffer an intraoperative durotomy are more likely to have a post-operative complication, but 6-week and 2-year functional health scores are similar to those that don’t suffer an incidental dural tear.
       

Hemorrhagic Blood Loss

  • Yu X, Xiao H, Wang R, Huang Y. Prediction of massive blood loss in scoliosis surgery from preoperative variables. Spine (Phila Pa 1976). 2013;38(4):350-355. doi:10.1097/BRS.0b013e31826c63cb
    • Adult spinal deformity surgery is associated with severe intraoperative blood loss. Risk factors for massive blood loss include preoperative Cobb angle larger than 50º,  planned osteotomy, or fusion of more than 6 levels.
       
  • Elgafy H, Bransford RJ, McGuire RA, Dettori JR, Fischer D. Blood loss in major spine surgery: are there effective measures to decrease massive hemorrhage in major spine fusion surgery? Spine (Phila Pa 1976). 2010;35(9 Suppl):S47-56.
    • Based on the current literature, there is little support for routine use of CS during elective spinal surgery.
    • With respect to the antifibrinolytics of the lysine analog class (tranexamic acid and aminocaproic acid), based on the available efficacy and safety data, we recommend that they be considered as possible agents to help reduce major hemorrhage in adult spine surgery. Concerns related to the use of aprotinin were such that we recommended against its use in spine surgery on the basis of the reports of increased complications. 51,57

POST-OPERATIVE RECOVERY

Rapid Recovery Protocol

Pain control

Post-operative Complications

Neurologic Complications

Infection

  • Simchen E, Stein H, Sacks TG, Shapiro M, Michel J. Multivariate analysis of determinants of postoperative wound infection in orthopaedic patients. J Hosp Infect. 1984;5(2):137-146. doi:10.1016/0195-6701(84)90117-8
    • Diabetes, prolonged operative times (>3 hours), body mass index more than 35, posterior approach, smoking, and number of intervertebral levels (≥7) are associated with an increased risk of SSI after spinal surgery.
       
  • Anderson PA, Savage JW, Vaccaro AR, et al. Prevention of Surgical Site Infection in Spine Surgery. Neurosurgery. 2017;80(3S):S114-S123. doi:10.1093/neuros/nyw066
    • Screening for nasal carriage of methicillin-sensitive S. aureus (MSSA) and MRSA 5-days prior to surgery with subsequent eradication treatment has been shown to reduce rate of infection in several surgical procedures.
       

Mechanical failure and Pseudarthrosis

Vision Loss

  • Baig MN, Lubow M, Immesoete P, Bergese SD, Hamdy E-A, Mendel E. Vision loss after spine surgery: review of the literature and recommendations. Neurosurg Focus. 2007;23(5):E15. doi:10.3171/FOC-07/11/15
    • Estimates for the incidence of post-operative vision loss after spinal surgery between 0.028 and 0.2%.
    • The most common diagnosis in patients in whom perioperative visual deficits develop after spine surgery is Ischemic Optic Neuropathy.
    • Perioperative factors that have been implicated in the development of ischemic optic neuropathy include intraoperative hypotension, duration of surgery, intraoperative blood loss, use of replacement fluids, and anemia.
    • Post-operative flat positioning should be avoided except in cases of hypotension.

 

Adult Spinal Deformity Enhanced Recovery After Surgery (ERAS)

  • Young R, Cottrill E, Pennington Z, Ehresman J, Ahmed AK, Kim T, Jiang B, Lubelski D, Zhu AM, Wright KS, Gavin D. Experience with an enhanced recovery after spine surgery protocol at an academic community hospital. Journal of Neurosurgery: Spine. 2020 Dec 25;34(4):680-7
    • In a subset of patients undergoing elective cervical or lumbar procedures, this retrospective single-center study determined that the implementation of an ERASS protocol that addresses the preoperative, intraoperative, and postoperative phases of care, was associated with decreased narcotic use, early hospital discharge, and “safe discharge.” (n=97) 
    • The patients in the ERASS group had lower POD 1 opiate use than the control group (26 ± 33 vs 42 ± 40 MMEs, p < 0.001. Additionally, patients in the ERASS group had shorter hospitalizations than patients in the control group (51 ± 30 vs 62 ± 49 hours, p = 0.047). On multivariable regression, implementation of the ERASS protocol was independently predictive of lower POD 1 opiate consumption (b = -7.32, p < 0.001).
    • The historic controls (n=146) were consecutive patients who underwent elective cervical or lumbar surgery the year prior to ERAS implementation, during a period in which there were no additional system-wide initiatives to reduce opiate consumption or hospital length of stay.
  • Soffin EM, Beckman JD, Tseng A, Zhong H, Huang RC, Urban M, Guheen CR, Kim HJ, Cammisa FP, Nejim JA, Schwab FJ. Enhanced recovery after lumbar spine fusion: a randomized controlled trial to assess the quality of patient recovery. Anesthesiology. 2020 Aug 1;133(2):350-63. 
    • This single-center prospective randomized controlled trial of patients undergoing primary one- or two-level lumbar fusion were grouped between those participating in an enhanced recovery pathway (n=25) versus those receiving “usual care.” (n=26)
    • Quality of Recovery-40 scores 3 days after surgery compared to those receiving standard perioperative care (179 ± 14 vs. 170 ± 16; P = 0.041). However, the difference was not deemed to be clinically significant.
    • The enhanced recovery protocol includes preoperative patient education on recovery expectations and multimodal analgesia, intraoperative use of propofol, ketamine, and dual antiemetics, and postoperative management with patient-controlled analgesia, scheduled medications, early physical therapy, and deep vein thrombosis prophylaxis to optimize recovery and minimize opioid use.
  • Kerolus MG, Yerneni K, Witiw CD, Shelton A, Canar WJ, Daily D, Fontes RB, Deutsch H, Fessler RG, Buvanendran A, O’Toole JE. Enhanced recovery after surgery pathway for single-level minimally invasive transforaminal lumbar interbody fusion decreases length of stay and opioid consumption. Neurosurgery. 2021 Mar 1;88(3):648-57. 
    • In this single-center retrospective study, patients undergoing a 1-level MIS transforaminal lumbar interbody fusion (MIS TLIF), patients enrolled in an ERAS pathway over a 20-month period (n=87) and compared to those undergoing the same procedure prior to the establishment of the ERAS protocol (n=212).
    • This ERAS pathway has shown a substantial decrease in LOS and opioid requirements in the immediate perioperative and postoperative period, but there were no difference in pain scores.
    • The ERAS protocol includes elements before, during, and after surgery. The preoperative phase involves medications (i.e. pregabalin and oxycodone) initiated by the anesthesiologist and nursing staff, the intraoperative phase includes focus on general anesthesia, IV acetaminophen, and local anesthetics administered by the surgeon and anesthesia staff, while the postoperative phase features a tailored pain management regimen with acetaminophen, hydrocodone, tramadol, antiemetics, cryotherapy, and early mobilization, alongside multidisciplinary care coordination.
  • Ifrach J, Basu R, Joshi DS, Flanders TM, Ozturk AK, Malhotra NR, Pessoa R, Kallan MJ, Maloney E, Welch WC, Ali ZS. Efficacy of an enhanced recovery after surgery (ERAS) pathway in elderly patients undergoing spine and peripheral nerve surgery. Clinical Neurology and Neurosurgery. 2020 Oct 1;197:106115. 
    • In this single-center retrospective study, elderly patients (65 years of age or older) undergoing spine and peripheral nerve surgery were group into those patients who participated in a newly established ERAS protocol (n=504) over a 19-month period and a historical control that underwent similar surgeries for a 4- month period prior to initiation of an ERAS protocol (n=60).
    • In the ERAS group, there was a significant reduction in the use of post-operative opioids at one month (36.2% vs. 71.7%, p < 0.001) and 3 months after surgery (33.0% vs. 80.0%, p < 0.001). The ERAS group showed improved mobilization and ambulation on POD 0 in compliance with our protocol compared to the control group (mobilization: 60.0% vs. 10.0%, p < 0.001; ambulation: 36.1% vs. 10.0%, p < 0.001), with no inpatient falls reported for either group.
    • Before surgery, patients received standardized information on the ERAS protocol and care guidelines, with referrals to specialized consultations based on opioid use, sleep apnea risk, glucose levels, and nutritional status, followed by preoperative carbohydrate loading; postoperatively, a multimodal pain regimen was implemented alongside early mobilization, venous thromboembolism prophylaxis, bowel function promotion, and standardized wound care, with most patients discharged with oxycodone and instructed to follow up with their primary care provider within two weeks.
  • Garg B, Mehta N, Bansal T, Shekhar S, Khanna P, Baidya DK. Design and implementation of an enhanced recovery after surgery protocol in elective lumbar spine fusion by posterior approach: a retrospective, comparative study. Spine. 2021 Jun 15;46(12):E679-87. 
    • In this single-center, retrospective cohort, consecutive patients that underwent a 1-3 level lumbar fusion were divided into a pre-ERAS group (n=496) and a post-ERAS group (n=316).
    • Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days; p=.03). The rate of postoperative complications, 60-day readmission, and 60-day reoperation did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8; p=0.039 --- ODI: 31.6 ± 14.2 vs. 28 ± 12.8; p=0.044) at 4 weeks after surgery. This difference however was not significant at 6 and 12 month follow-up.
    • The ERAS protocol begins with comprehensive patient education and optimization of health before surgery, followed by a preemptive analgesia plan, strict infection control measures, intraoperative multimodal pain management, and postoperative early mobilization, all aimed at minimizing opioid use, enhancing recovery, and providing continuous support through telephonic follow-ups and a 24/7 helpline.
  • Feng C, Zhang Y, Chong F, Yang M, Liu C, Liu L, Huang C, Huang C, Feng X, Wang X, Chu T. Establishment and implementation of an enhanced recovery after surgery (ERAS) pathway tailored for minimally invasive transforaminal lumbar interbody fusion surgery. World neurosurgery. 2019 Sep 1;129:e317-23. 
    • In this single-center retrospective study, patients undergoing a 1-level MIS transforaminal lumbar interbody fusion (MIS TLIF), patients enrolled in an ERAS pathway (n=44) compared to those undergoing the same procedure prior to the establishment of the ERAS protocol (n=30).
    • The ERAS group demonstrated a shorter length of stay and lower costs compared to the pre-ERAS group, with no significant differences in complication rates, 30-day readmission, or reoperation rates. Additionally, the ERAS group experienced reduced blood loss, operative time, intraoperative fluid infusion, and postoperative drainage.
    • The ERAS protocol includes patient education, structured fasting, preemptive analgesia, timely antimicrobial prophylaxis, maintenance of normothermia and normovolemia, tranexamic acid use, local analgesia, multimodal postoperative pain management, early nutrition, and mobilization, all of which were more standardized and proactive compared to their prior conventional practices.
  • Debono B, Wainwright TW, Wang MY, Sigmundsson FG, Yang MM, Smid-Nanninga H, Bonnal A, Le Huec JC, Fawcett WJ, Ljungqvist O, Lonjon G. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. The Spine Journal. 2021 May 1;21(5):729-52. 
    • The authors reviewed 256 articles to develop consensus statements for 21 ERAS items, in which 28 recommendations were made.
    • Preoperative recommendations for lumbar spine fusion include patient education, smoking and alcohol cessation, nutritional assessment, and minimizing preoperative fasting, while intraoperative recommendations focus on infection control, maintaining normothermia, and using multimodal anesthesia and analgesia techniques. Postoperatively, early oral nutrition is encouraged, and the use of urinary catheters is discouraged for short-segment fusions, with a strong emphasis on individualized surgical techniques and fluid management.
    • Multiple studies demonstrates that the successful implementation of ERAS protocols for spine surgery is an inherently multidisciplinary concept, and in fact, surgical techniques do not matter in the overall management.
  • Debono B, Corniola MV, Pietton R, Sabatier P, Hamel O, Tessitore E. Benefits of enhanced recovery after surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction. Neurosurgical focus. 2019 Apr 1;46(4):E6. 
    • The authors retrospectively compared patient from two 2-year periods—pre-ERAS (2012–2013) [n=1,920] and post-ERAS (2016–2017) [n=1,563] —across three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion.
    • The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. (ALIF: 6.06 ± 1.1 to 3.33 ± 0.8 days; p < 0.001), (ACDF: 3.08 ± 0.9 to 1.3 ± 0.7 days; p < 0.001, and (Posterior Fusion: 6.7 ± 4.8 to 4.8 ± 2.3 days; p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high.
    • The ERAS protocol includes a dedicated preadmission unit where patients receive briefings and consultations with surgeons, anesthesiologists, and physiotherapists, followed by pre- and postoperative education by ERAS nurses; intraoperative procedures focus on minimally invasive techniques and early recovery strategies, while postoperative care emphasizes multimodal opioid-sparing pain management, rapid discharge planning, and 24/7 follow-up support via phone and a dedicated mobile app. 
  • Angus M, Jackson K, Smurthwaite G, Carrasco R, Mohammad S, Verma R, Siddique I. The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery. Journal of Spine Surgery. 2019 Mar;5(1):116. 
    • This is a single-center, retrospective study that evaluated complex spine patients that were managed under a ERAS pathway over a 2-year period (n=214), and those that cared for during the 3 years leading up to the introduction of the ERAS protocol (n=412).  
    • The implementation of the ERAS service led to improved patient satisfaction, with 100% of patients reporting satisfaction postoperatively compared to 84% before ERAS, and it was independently associated with this improvement (OR: 2.5, p=0.016); additionally, the average length of stay (LOS) decreased significantly for both degenerative scoliosis and complex fixation patients, with no increase in 30-day readmission rates, while staff reported high satisfaction and positive impacts from the ERAS protocol.
    • The ERAS protocol involved utilizing the waiting period for patient optimization through education, therapy, vitamin D optimization, and multidisciplinary team engagement, with comprehensive preoperative planning and perioperative management, including carbohydrate loading, analgesia regimes, and early mobilization; postoperative care follows structured daily goals, and discharge includes close follow-up with the ERAS team. 
  • Adeyemo EA, Aoun SG, Barrie U, Nguyen ML, Badejo O, Pernik MN, Christian Z, Dosselman LJ, El Ahmadieh TY, Hall K, Reyes VP. Enhanced recovery after surgery reduces postoperative opioid use and 90-day readmission rates after open thoracolumbar fusion for adult degenerative deformity. Neurosurgery. 2021 Feb 1;88(2):295-300 
    • In this single-center retrospective study, adult patients undergoing open thoraco-lumbar-pelvic fusion for degenerative scoliosis were group into those patients who participated in a newly established ERAS protocol (n=67) and a historical control that underwent similar surgeries prior to initiation of an ERAS protocol (n=57). 
    • Patients in the ERAS group consumed significantly lower amounts of postoperative opioids (248.05 vs 314.05 MED, P = .04), a lower rate of urinary retention requiring catheterization (5.97% vs 19.3%, P = .024) and of severe constipation (1.49% vs 31.57%, P < .0001), and fewer readmissions after their surgery (2.98% vs 28.07%, P = .0001). 
    • The ERAS protocol involved comprehensive preoperative care, including behavioral health, smoking cessation, geriatric consultations, and nutritional optimization, intraoperative management with tranexamic acid, epidural analgesia, and strict blood management strategies, and postoperative care focused on early mobilization, multimodal pain control, and minimizing opioid use. 

Spinal Deformity Surgery Team Checklist

The Spinal Deformity Surgery Team Checklist is a suggested list of items for centers performing spinal deformity surgery to support ongoing efforts to improve safety. The material is intended to present a suggested approach that may be helpful to centers performing spinal deformity surgery.

Download the checklist as a pdf or as a customizable word document.

A suggested addition to the “Before Turning” section from our members is: Consider obtaining baseline neuromonitoring data prior to positioning prone for complex cases.

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SRS Statements and Practice Parameters

SRS statements and practice parameters assist healthcare professionals by providing information on clinical and scientific advances. These documents reflect the most current guidance available from the SRS on clinical topics related to spine deformity.

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